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Deficiency Records for Edinboro Manor
A list of the most recent deficiencies for Edinboro Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Edinboro Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2024-02-15 | 2024-04-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-02-15 | 2024-04-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-15 | 2024-04-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-02-15 | 2024-04-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-15 | 2024-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-15 | 2024-04-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-15 | 2024-04-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-15 | 2024-04-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-02-15 | 2024-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-15 | 2024-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-22 | 2024-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-22 | 2024-04-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-03 | 2023-04-05 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-03-03 | 2023-04-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-03 | 2023-04-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-03 | 2023-04-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-03 | 2023-04-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-03 | 2023-04-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-03-03 | 2023-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-03 | 2023-04-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-03 | 2023-04-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-03-03 | 2023-04-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-03 | 2023-04-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-03 | 2023-04-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-03 | 2023-04-05 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-03 | 2023-04-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-03 | 2023-04-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-28 | 2022-06-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-28 | 2022-06-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-28 | 2022-06-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-04-28 | 2022-06-22 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-26 | 2022-06-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-05 | Not Fixed | Y |
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